NORCET 2 -2021 (Shift…: A nurse is going to start the peritoneal dialysis. Which is a first priority action of the nurse? (NORCET 202…

NORCET 2 -2021 (Shift-2)

Medical & Surgical Nursing

Medium

Appeared in: NORCET 2 -2021 (Shift-2)

Explanation

Warming the dialysate solution to body temperature (around 37°C or 98.6°F) is a critical first step to ensure patient comfort and procedural effectiveness.
Instilling cold dialysate can cause abdominal pain, cramping, and a shock-like state.
Warm fluid promotes vasodilation of the peritoneal blood vessels, which increases the surface area for diffusion and enhances the clearance of metabolic waste products.

Option A: Applying a Foley catheter is an invasive procedure that increases infection risk and is not a routine first step. The correct action is to encourage the patient to void voluntarily to empty their bladder.
Option B: Assessing for a bruit (a whooshing sound) and a thrill (a palpable vibration) is the standard method to check the patency of an arteriovenous (AV) fistula or graft, which is the vascular access for hemodialysis.
Option C: The standard position for the inflow phase of peritoneal dialysis is supine or semi-Fowler's. This uses gravity to help the dialysate fill the abdominal cavity evenly.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Priority nursing actions for peritoneal dialysis in the correct sequence, documenting the action clearly, and monitoring for the expected response.
Patient safety is paramount. Never warm dialysate in a microwave, as it can create 'hot spots' that can cause severe internal burns to the peritoneum. Use a commercial warmer or dry heat methods.
Peritonitis is the most frequent and serious complication of PD. Strict aseptic technique during all connections and disconnections is the most important nursing intervention to prevent it. Cloudy outflow fluid is a key sign of peritonitis and must be reported immediately.
What if the outflow is significantly less than the inflow? The nurse should first check for kinks in the tubing, then have the patient change position (e.g., turn from side to side, sit up) to help drain the remaining fluid. Constipation is a common cause of poor outflow, so assessing bowel habits is also important.

How to Approach the Question

First, identify the core of the question: it asks for the 'first priority action' before starting peritoneal dialysis.
Analyze each option in the context of the specific procedure (peritoneal dialysis).
Option A (Foley): Is this routine? No, it's invasive. The non-invasive action (voiding) is preferred.
Option B (Bruit/Thrill): Does this apply to PD? No, this is a classic assessment for hemodialysis access. This is a key distractor testing your ability to differentiate between the two dialysis types.
Option C (Positioning): Is this the correct position for starting the procedure (inflow)? No, supine/semi-Fowler's is standard for inflow.
Option D (Warming fluid): Is this necessary for patient safety and comfort? Yes, cold fluid in the abdomen causes cramping and is less effective. This is a critical preparatory step.

Concept Tested & Keywords

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E6 Nursing Fundamentals Taylor p. 610-612

E6 Ghai Essential Pediatrics(pp 26-904 of 913) p. 783-785